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L prescription, non-prescription, vitamins, home remedies, or herbal medication Name Dose (ex: mg/pill) How often? Good Poor Date medication started Medication Allergies Social History YES NO Marital Status: single Spouse / Partner Name: married divorced widowed other Who lives at home with you? Do you have an end of life directive? (Living will, medical power of attorney, etc.) Tobacco Use: (type & amount per day) Date quit Alcohol Use: (type &frequency) Is alcohol a concern for you.
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